HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 31 VEST WAY 10/16/2025 Commonwealth of Massachusetts Town of North Andover
4 W> City/Town of -- T 16 2025
System Pumping Record
Farm 4
DepartMentent
DEP has provided this form for use by local Boards of Health. Other forms may be. used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.:351, -------__�__.. _.._..._. _--
_.__......._____. HOUSE: front pack side rear( eftyriF,ht
A. Facility Information BUILDING: front back side rear left riffs
Important:When
DECK: tinder
filling out forms 1, Systenn Location:
use only the tab
on the computer,key to move your Address
cursor-do not MA ( �/?
key.
use the return __�_____._____...__ ___----..______._. —___.__._....._.. __..__.._v__._ ____ �_ �_____._. __ _.______._._.__.___.__.....__..
City/Town State Zip Code
2. System owner:
fl)fEI62 r p�
G Nar1ne
I=111U
Address (if different from location) --- �— —
MA
cltytTown state Zip code
Telephone Number
_.. ._.. ____ .__-- _..________. _ _--__.._ .__....... ..-, .._
B. Pumping Record
1. Date of Pumping Da ' - - --- 2 Quantity Pumped
t Lallans
3, Component: Cesspools) Septic Tank ❑ Tight Tank ❑ Grease Trap
[_} Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? Yes ❑ No
5, observed condition of component pumped;
& System Pumped By:
Dave Tine ��ass 1 AA�5E Mass I AD31Z
m Nae VehICIE L cCe n4f.,Ns lFvTber
Bateson Enterprises, Inc.
Company
7. I_ tion where contents were disposed:
Signature of Hauler Date
Signature of ficceiving Facility(or attach facolity rece'spt} C1ate ��-�- -
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